1例抗菌药物相关性腹泻患者的全程药学监护

目的 探讨抗菌药物相关性腹泻（antibiotic-associated diarrhea，AAD）的治疗策略和临床药师的工作意义。方法 对临床药师参与的1例AAD患者的药物治疗全过程以及其他用药进行药学监护，提出合理的用药建议。结果 AAD患者对万古霉素不敏感，在抗菌药物暂无法停用的情况下，临床药师建议加用曲美布汀片和双歧杆菌三联活菌胶囊，联合蒙脱石散和地衣芽孢杆菌活菌胶囊处理，患者腹泻症状好转；应用头孢哌酮/舒巴坦抗感染治疗期间，临床药师建议可预防使用维生素K，避免发生出血事件；并且患者长期服用的美托洛尔缓释片可经胃管给药。结论 非艰难梭菌感染或非感染性AAD对万古霉素的反应性不明确，但抗蠕动剂可能有效。目前仍需更多的研究证实头孢哌酮用药期间维生素K作为预防措施的价值。临床药师须密切关注用药细节，发挥专业优势，为患者提供优质和个体化的药学服务。

Whole-course Pharmaceutical Care of a Patient with Antibiotic-associated Diarrhea

OBJECTIVE To explore the therapeutic strategy of antibiotic-associated diarrhea (AAD) and the work significance of clinical pharmacists. METHODS Pharmaceutical care was given to a patient with AAD who was participated by clinical pharmacist during the whole course of drug treatment and other drugs in use, and reasonable drug use suggestions were put forward. RESULTS When the patient''s AAD was insensitive to vancomycin and antibiotics could not be stopped, clinical pharmacist suggested adding trimebutine tablets and bifidobacterium triple viable capsules, combined with montmorillonite powder and licheniform bacillus viable capsules, and diarrhea symptoms improved; during the anti-infective treatment with cefoperazone/sulbactam,clinical pharmacist recommend that vitamin K be used to prevent bleeding;metoprolol sustained-release tablets [betaloc] can be administered by gastric tube. CONCLUSION The reactivity of non-clostridium difficile or non-infectious AAD to vancomycin is not clear, but anti-peristaltic agents may be effective. More studies are needed to confirm the value of vitamin K as a preventive measure during cefoperazone administration. Clinical pharmacists should pay close attention to the details of drug use, give full play to their professional advantages, and provide patients with high quality and personalized pharmaceutical care.